Coalinga Regional Medical Ctr DP/SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accuracy of documentation according to professional standards for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when the assistant director of nurses/minimum data set (ADON/MDS) nurse documented and electronically signed for the social services director (SSD) on 1/3/25 and 1/6/25 in Resident 1, Resident 2 and Resident 3 ' s multidisciplinary care conference (MCC-meeting that could consists of director of nurses, physician, dietary staff, therapy staff, social services, activities, resident and resident representative to discuss resident care) notes. This failure resulted in falsified documentation and could have caused delay in care resulting from the inaccuracy of the documentation for Resident 1, Resident 2, and Resident 3. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 1), when Resident 1 was left outside for approximately one hour without supervision and the temperature was 92 degrees Fahrenheit on 9/29/24. This failure resulted in Resident 1's body temperature to reach 101.1 degrees Fahrenheit (normal body temperature range from 97 degrees to 99 degrees Fahrenheit) and elevated heart rate of 136 beats per minute (normal heart rate for adults is between 60-100 beats per minute) and had the potential for Resident 1 to experience heat exhaustion, dehydration and/or sunburn of the skin. Findings: During a review of Resident 1's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain a comfortable environment for one of 35 residents (Resident 12) when the room temperature, measured by the California Department of Public Health (CDPH) thermometer, in Resident 12 ' s room was 84 degrees Fahrenheit. This failure had the potential to result in dehydration (body does not have enough fluids) and heat exhaustion (body overheats and unable to cool itself) for Resident 12. Findings: During a concurrent observation and interview on 6/7/24 at 11:59 p.m. with the unit clerk (UC), the temperature in Resident 12 ' s room was observed. The temperature with the CDPH handheld thermometer read 84 degrees Fahrenheit. The unit clerk was observed checking the temperature of Resident 12 ' s room with the facility ' s handheld thermometer, the temperature was observed at 81 degrees Fahrenheit. The UC stated Resident 12 ' s room felt hot and hot air was being transferred into the room through the air conditioner vent. The UC stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with professional standards for 24 of 31 residents when medication blister packs (a type of packing used for resident medication) had orange and green stickers placed over the expiration dates. These failures placed residents at risk for being administered expired medications which may have no longer had the same efficacy and/or side effects. Findings: During a concurrent observation and interview on 1/24/24 at 10:12 a.m., with Infection Preventionist (IP - professional who make sure healthcare workers and residents are doing all the things they should to prevent infections) at medication cart 1, 24 of 31 residents' medication blister packs were observed with no visible expiration date. The expiration date was covered with orange and green stickers indicating am (morning) and pm (afternoon) shifts. IP stated he could not find an expiration date on medication blister packs. IP stated not being able to see expiration date put the residents at risk to receive expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to competently care for 49 of 49 residents at the facility during day-to-day operations and emergencies. This failure had the potential for residents not to receive the services needed to achieve and maintain the highest practicable well-being during day-to-day operations and during an emergency. Findings: During the entrance conference interview with the Administrator (ADM) on 1/22/24, at 9:54 a.m., the facility assessment was requested which was part of the list of documents he needed to provide in a timely manner. The Entrance Conference form indicated the ADM was to provide the facility assessment within 4 hours of entrance. During an interview on 1/24/24 at 10:15 a.m. with the ADM, the ADM stated the skilled nursing facility (SNF) was part of the general acute care hospital (GACH) and the facility assessment was part of the campus wide assessment. The ADM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain a clean and homelike environment for three of three sampled residents (Residents 6, 147 and 19), when: 1. The door frame of Resident 6's Room had missing and chipped paint. 2. Ceiling tiles were peeling, paint missing from Resident 147's room. 3. Resident 19's wall had a TV bracket in place without a television (TV) for over one month, which Resident 19 complained to staff about not having a TV in her room. These failures had the potential to violate the residents' rights to have a clean, sanitary, and comfortable homelike environment. Findings: 1. During a review of Resident 6's admission Record (AR), dated 1/25/24, the AR indicated Resident 6 was admitted on [DATE] with diagnoses which included quadriplegia (a form of paralysis [the loss of the ability to move and sometimes to feel anything] that affects all of a person's limbs and body from the neck down), chronic pulmonary embolism (blockage of the pulmonary [lung] arteries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice when: 1. Facility staff did not obtained consent for psychoactive medication (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behaviors), vaccinations (preparation to stimulate the body's immune response against disease), side rails and his Physician Orders for Life-Sustaining Treatment (POLST-a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) while lacking decision-making capacity for informed consent (healthcare provider educates a patient about risks, benefits and alternatives of an intervention and the patient must be competent to make voluntary decisions) for one of three sampled residents (Resident 13) . These failures placed Resident 13 at risk for harm from giving consent without full understanding of the risks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There was one unwrapped frozen food item on the floor, under the food rack in the walk-in freezer. This failure had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Residents' meal trays were reheated by staff, who were not trained on the proper method to safely reheat food for residents whose meal trays were held to be consumed at a later time. This failure had the potential for growth of pathogenic bacteria and cause food born illness (illness caused by ingestion of contaminated food or beverages) to residents who consumed the improperly reheated food and placed residents at risk for cross-contamination (the process by which bacteria or other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of two sampled residents (Resident 98), when the staff failed to answer Resident 98's call light in a timely manner. This failure resulted in Resident 98 urinating on himself and sitting in his urine for approximately 21 minutes. Resident 98 verbalized feeling felt frustrated, embarrassed, and helpless. Findings During a review of Resident 98's admission Record (AC), undated, the AC indicated, Resident 98 was admitted to the facility on [DATE] for rehabilitation after closed fracture of the lower end of left femur (broken upper bone of leg), with diagnosis of respiratory failure (a serious condition which makes it difficult to breathe), muscle weakness, chronic combined systolic and dystolic heart failure (heart does not pump enough blood for body's needs), left artificial hip joint, benign prostatic hyperplasia without lower urinary tract symptoms, (enlarged prostate). During a review of Residents 98's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure kitchen staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, in accordance with professional standards for food service safety when one of two sampled kitchen staff (Cook 2) were not able to verbalize the appropriate method of the food cool down process. This failure had the potential to result in the growth of spore-forming bacteria (highly resistant, dormant [no metabolic activity] structures formed in response to adverse [unfavorable] environmental conditions) or toxin-forming bacteria (organisms which are capable of producing toxins [substances that are poisonous to humans]) on improperly cooled food, resulting in bacterial food born illness (illness caused by ingestion of contaminated food or beverages) for 49 out of 49 residents who consumed food from the kitchen. Findings: During a concurrent observation and interview on 1/23/24 at 9:05 a.m. with [NAME] (CK) 2 in the kitchen, CK 2 was asked about the cool down process for hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to electronically submit the Payroll-Based Staffing Journal (PBJ - staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters (fourth quarter) in 2023 (July 1, 2023 through September 1, 2023). This failure had the potential for resident's in the facility to not have staff to resident ratio necessary to provide safe and quality care and prevented the provision of complete and accurate direct care staffing information. Findings: During a review of facility's Offsite Prep ([undated] -survey information provided by CMS to review prior to surveying facility). The Offsite Prep indicated, the facility did not submit the PBJ report for the fourth quarter of fiscal year 2023. During an interview on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the DON stated she was not responsible for submitting the PBJ report. The DON stated she was aware the PBJ report was not submitted for the fourth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. One of two sampled Licensed Vocational Nurses (LVN 2) tested Resident 18's blood sugar and placed the contaminated (infected by contact) blood glucose (sugar) monitor (glucometer- device that measures blood glucose levels) into the medication cart drawer without being cleaned or disinfected. This failure had the potential to expose facility residents to blood borne pathogens (infectious microorganisms present in the blood). 2. One of three sampled residents, Resident 32's oxygen (a life-saving colorless, odorless gas) tubing was curled up on the floor. This failure was a potential trip and infection control hazard for Resident 32. Findings: 1. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to keep one of three sampled Residents (Resident 1) safe, when Resident 1 eloped [left the facility unsupervised] from the facility and was missing for two hours. The facility failed to follow its policy and procedure titled, Wandering and Elopements, when it did not create a care plan or interventions for wandering/elopement for this resident. This failure resulted in Resident 1 eloping from the facility, being found two hours later and had the potential to cause harm even death to the Resident 1. Findings: During a review of Resident 1's admission Record (AR-provides demographic information, responsible party and contacts financial and insurance) dated 7/28/21, printed at 12:01 p.m., the AR indicated Resident 1 was admitted on [DATE] with primary diagnosis of Acute Respiratory Failure (occurs when the respiratory system is unable to adequately absorb oxygen or excrete carbon dioxide), Chronic Respiratory Failure (ongoing condition that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the rights of one of three residents (Resident 1), when Resident 1 asked to be sent to the hospital for worsening of his sinus issues and the licensed nurse (LVN 1) told him he had two options: one wait for the doctor to come in and assess him or leave to go to the hospital by himself against medical advice (AMA). This failure resulted in Resident 1 getting upset and feeling like he was not being treated appropriately so he left in his wheelchair (WC) and wheeled himself to the Emergency Department (ED) of the hospital next door. Resident 1 was admitted to this hospital with Sinusitis (sinus infection) and placed on antibiotics (medication used to treat infections) and prednisone (steroid used to decrease swelling). Findings: During an interview on 7/28/21, at 9:10 a.m., with Resident 1, Resident 1 stated he was a resident at this facility, and he did not receive proper care and treatment. Resident 1 stated on 7/20/21 he asked licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store drugs and biologicals according to professional standards of practice and facility policy and procedure when a multi-dose vial of tuberculin (TB) testing serum (injected under the skin to test for tuberculosis (infectious bacterial disease characterized by nodules in the tissue and lungs) opened 8/21/21 and expired 9/20/21 was in the refrigerator area designated for use; and a 1 liter bottle of [Brand 1.5] gastrostomy tube (tube surgically inserted in the abdomen for access to the stomach) enteral feeding formula which had expired 6/21 (expired 4 months prior) was on the shelf with other formulas designated for resident use; and 16 bottles of expired enteral feeding [Brand 1.0] and 6 bottles of expired enteral feeding [Brand 1.2] were stored inside the dry food storage room. The facility did not implement a system to routinely monitor the medication storage room for expired products. These failures had the potential to affect 16 of 16 sampled residents and 15 unsampled residents if medications and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility's administrative staff failed to provide effective oversight and necessary resources to ensure resident care and services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of nine sampled Residents (Resident 8, Resident 9, Resident 10, Resident 110, and Resident 118), when the facility did not implement elements from their initial certification survey plan of correction (POC) for F-tag 692. (Cross reference 692) This failure had the potential to result in nutritional needs not being met for Residents 8, 9, 10, 110 and 118. Findings: During an interview on 2/16/22, at 11:36 a.m., with the Administrator (ADM), the ADM stated the facility had a quality assurance and performance improvement (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) committee meeting on 12/30/21 to discuss the initial certification survey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to identify, develop and implement an effective QAPI (Quality Assurance and Performance Improvement- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. (Cross reference tag F-692) This failure had the potential to affect the quality of care, quality of life, services and safety of the facility's residents. Findings: During a concurrent interview and record review on 2/16/22, at 11:36 a.m., with the administrator (ADM), the facility's document titled, Quality Assessment and Assurance Committee Minutes of Meeting, dated 12/30/21 was reviewed. The ADM stated the topic of the QAPI committee was the plan of correction (including tag F-692) from the initial certification survey. The ADM reviewed the QAPI minutes and stated the minutes were not complete. The ADM stated the discussion during the QAPI meeting had not been documented. The ADM reviewed the QAPI minutes and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to maintain a clean and safe environment for all residents in the facility when: 1.The ice machine located in the Skilled Nursing Facility (SNF) Supply Room was observed to have pink and green substance and white residue and to not be in a sanitary condition; the ice machine manufacturer's instructions for cleaning were not followed for two of two ice machines. 2.Two of two staff members (Licensed Vocational Nurse- LVN 4 and Certified Nursing Assistant- CNA 5) were observed to not use standard hand washing procedures while exiting a contact isolation room. These failures had the potential to cause food born illnesses, transmission of communicable diseases and infections to all residents. Findings: 1.During a concurrent observation and interview on 10/5/21, at 9:35 a.m., with the Maintenance Staff (MAINS) 1, the ice machine 1 located in the kitchen was inspected. The MAINS 1 stated he used a nickel safe generic cleaning solution to clean, sanitize and descale the ice machine. During a concurrent observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for five (5) of 16 sampled residents (Residents 110, ,114, 117, 122, and 128) when: 1. Resident 114's MDS assessment for weight loss were not coded accurately. 2. Residents 110, 117, 122, and 128's MDS assessment for the influenza (A common viral infection that can be deadly, especially in high-risk groups) and Pneumococcal vaccines (Vaccine to prevent pneunomia (Infection that inflames air sacs in one or both lungs, which may fill with fluid.) were not coded accurately. 3. Resident 128's MDS assessment for falls since admit were not coded accurately. These failures had the potential for the facility to not provide the necessary care and services to meet the resident's individualized needs and placed them at risk for decline in health and safety. Findings: 1. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were followed in the kitchen when: 1. Proper procedures were not followed for cooling ambient (foods prepared at room temperature) foods. 2. The ice machine drainpipe located in the SNF supply room did not have an air gap. 3. The can opener blade was dirty. These failures had the potential to place the 31 residents who received food prepared in the facility kitchen at risk for foodborne illness. Findings: 1. On 10/6/21 at 3:41 p.m. an interview was conducted with the [NAME] 2 and the DM 2 regarding the preparation of tuna salad. The [NAME] 2 stated the cans of tuna were stored in the storeroom. The [NAME] 2 stated once the tuna salad was mixed with the mayonnaise and other ingredients, she took the temperature and wrote the temperature on a piece of paper. The [NAME] 2 then put the tuna salad in the refrigerator. Half an hour before meal service, the [NAME] 2 took the temperature of the tuna salad and records that in the logbook. The DM 2 was unable to confirm any recorded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to ensure three of five sampled residents (Resident 110, Resident 117, and Resident 128) were offered and/or received the Pneumococcal vaccinations. The facility also failed to ensure one of five sampled residents (Resident 122) was provided the education to make an informed decision to accept the Pneumococcal vaccine. These failures placed the three residents (Resident 110, 117, and 128) at risk of becoming infected with pneumonia and took away one resident (Resident 122) right to make an informed decision because the education was not provided on the pneumonia vaccine before it was given. Findings: During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the Director of Nursing (DON), Resident 110's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/16/21, was reviewed. The DON confirmed the MDS for Resident 110 indicated the Pneumococcal vaccine was not offered. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the call light was within the reach of residents to call for staff assistance for three of 16 sampled residents (Resident 108, 110 & 128). These failures had the potential for Resident 108, 110, and 128 not being able to call for assistance if assistance was needed. Findings: During a review of Resident 110's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission RECORD, dated 10/5/21 at 3:45 p.m., indicated, . Resident 110 was admitted on [DATE] for Infection of amputation (surgically cutting off a limb) stump, left lower extremity . Osteomyelitis (inflammation of bone or bone marrow, usually due to infection) . Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar.) . Cerebral infarction (stroke- a result of disrupted blood flow to the brain) . muscle weakness . Phantom limb…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess one of three sampled residents (Resident 108) for removal of an indwelling (tube left within a body organ) foley catheter placed after admission. This failure resulted in pain to Resident 108's penis and the potential harm of continued infection and discomfort. Findings: During a review of Resident 108's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission RECORD, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes (A chronic condition that affects the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who use psychotropic (drug that effects brain activity) medications receive a Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or discontinued), for one of sixteen sampled residents (Resident 114). This failure placed Resident 114 at risk for prolonged use of psychotropic medication and increased risk for adverse medication side effects. Findings: During an observation, on [DATE] at 9:30 a.m., Resident 114 was asleep in her bed. During an observation, on [DATE] at 11:00 a.m., Resident 114 was asleep in her bed with the blanket over her head. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, on [DATE] at 1:30 p.m., Resident 114 was asleep in her bed. LVN 2 stated Resident 114 had gotten up to eat but went back to bed. LVN 2 stated Resident 114 occasionally slept all day due to her diagnosis of sleep disorder about one time per week.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals served to the facility residents when one [NAME] (Cook 1) did not follow the facility menu, did not calibrate a food thermometer correctly, did not take food temperatures correctly, and did not know the correct thawing procedure when using the sink thawing method for meats. These failures had the potential to place the 31 residents who received food prepared in the kitchen at risk for foodborne illness and to not meet their nutritional needs which could lead to nutritional related health concerns. Findings: 1a. Review of the job description for the [NAME] position, signed and dated 3/14/21 by the [NAME] 1 showed, the cook position was responsible for checking the menu and production sheet for the meal, and lunch and dinner meal preparation. Review of a type-written letter signed by the RD 1 on 10/5/21 at 12:17 p.m., showed the high calorie, high protein diet (HiCal/Pro) was interchangeable with the large portion diet. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the facility menus were followed when: 1. High Calorie/High Protein (HiCal/Pro) diets were not followed for one sampled resident (Resident 112) and one nonsampled resident (Resident 115) out of 31 residents and, 2. The diet spreadsheet was not followed for all diets served in the facility. These failures posed the risk for 31 residents who received food prepared in the kitchen to not meet their nutritional needs. Findings: 1. Review of a type-written letter signed by the RD 1 on 10/5/21 at 12:17 p.m., showed the HiCal/Pro diet was interchangeable with the large portion diet. Review of the facility document titled Diet Spreadsheet, Fall/Winter 2 undated, showed for Wednesday, HiCal/Pro diets should have received three ounces pit ham, half cup of corn souffle, half cup of roasted zucchini and red peppers, two dinner rolls, 2 packets of margarine, half cup of spiced apricots and eight ounces of whole milk. During an observation of the lunch meal tray line on 10/6/21 at 11:42 a.m., with the [NAME] 1, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility failed to ensure one of 16 sampled residents' (Resident 118) food preferences were honored when: Resident 118 did not receive cranberry juice with her lunch meal as she requested. Resident 118 received milk with her lunch meal after informing the facility she did not like milk. This failure caused Resident 118 to not receive the beverage she preferred. Findings: During the lunch meal observation on 10/5/21 at 12:08 pm. Resident 118 complained she never received the cranberry juice she requested with her meals. Her lunch meal did not include cranberry juice on her tray but rather included an 8 oz glass of milk for the beverage. Resident 118 stated she did not like milk but received it with her meals. On 10/5/21 at 12:20 p.m. an interview was conducted with the DSD. The DSD confirmed Resident 118 received milk with her lunch meal and did not receive cranberry juice. Review of Resident 118 meal ticket showed for beverages: 4 ounces cranberry juice and for dislikes: milk to drink. On 10/08/21 at 3:48 p.m., an interview with conducted with the RD 1 and the DM 2 regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nutritional assessments were performed by a qualified Registered Dietitian for one of 16 sampled residents (Resident 114) when: The Dietary Manager failed to meet the qualifications and skill set to assess the facility's residents' nutritional status. This failure posed the risk for residents' nutritional needs to not be met. Findings: The online dictionary defines review as a formal assessment or examination of something with the possibility of intention of instituting change if necessary this definition, therefore, implies a review as an assessment, a role designated for the RD. Based on state regulations (California business and professions code 2586), the RD is the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. Review of the facility's policy and procedure revised September 2011,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.